Medical scheme myths and misconceptions

There is often confusion about how medical scheme cover and benefits work.

Here are some facts.

Do medical schemes make profit?

Medical schemes are not profit-making organisations. According to regulation, residual money left after the Scheme has paid all claims for the year has to be put in the Scheme’s reserves. These reserves belong to the members of the Scheme.

Can a medical scheme refuse to give someone membership?

Restricted (closed) medical schemes like Remedi are administered on behalf of companies for their staff and their families. Open medical schemes cannot refuse anyone membership.

If applicable, a scheme may impose late-joiner penalties, three-month general waiting periods or condition-specific waiting periods of no more than 12 months on new members.

Please note that you cannot apply for membership on a medical scheme while you have an active membership on another medical scheme.

All medical schemes in South Africa operate in accordance with the Medical Schemes Act 131 of 1998, and are regulated by the Council for Medical Schemes.

Can a medical scheme exclude a member’s pre-existing condition from cover?

No. They may impose a condition-specific waiting period for any conditions the person has when they join the scheme, but the exclusion is never permanent. The maximum waiting period for cover for a pre-existing medical condition is 12 months.

Please note: It is considered fraud when a member does not disclose their pre-existing conditions when they join a scheme — and that will have serious consequences.

Medical inflation occurs worldwide, not just in South Africa

Worldwide all the factors below contribute to high medical inflation:

• High equipment and medicine costs
• The spiralling costs of private healthcare
• Overtreatment in the private sector
• The increase in lifestyle-related diseases.

To have 100% cover does not necessarily mean the member pays nothing. Schemes normally give cover at 100% of the medical scheme rate, which may be lower than the healthcare provider’s rate. Healthcare providers can be doctors, hospitals, physiotherapists, pharmacies and many more. If a healthcare provider charges more than the medical scheme rate, the member must pay the difference between 100% of the medical scheme rate and the amount the healthcare provider charges.

For example: The scheme rate for a specific procedure is R100. The doctor charges R110 to do the procedure. The scheme will the pay R100 and the member must pay the provider R10 from their own pocket.